lidocaine patch (Lidoderm®, ZTLido™)

Prior Authorization Call Line: 1-877-309-9493

Prior Authorization Fax Line: 1-800-268-2990

Prior authorization for lidocaine patch has been implemented to reinforce appropriate use
and to ensure utilization consistent with the approved indication. Requests for prior authorization of
lidocaine patch can be initiated by either prescribers or their authorized agents. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).

Prior authorization requirements:

Prescribers, or their authorized agents, are required to respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug.

Prescriptions can be written for a 30-day supply with up to 2 refills.